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Updating the Guideline Methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC)

Background

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee made up of 14 external infection control and public health experts who provide guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (DHHS) regarding the practice of healthcare infection prevention and control, strategies for surveillance, and prevention and control of healthcare associated infections (HAIs) in United States healthcare facilities. As such, one of the primary functions of the committee is to issue recommendations for preventing and controlling HAIs in the form of guidelines and less formal communications.1, 2 Currently, HICPAC guidance documents are available on its website for download 1, and a number of additional documents have been published since HICPAC's inception, most commonly in Morbidity and Mortality Weekly Report (MMWR), Infection Control and Hospital Epidemiology (ICHE), and the American Journal of Infection Control (AJIC).

The strength of the HICPAC guidance documents stem from their process of development as well as their content and organization. HICPAC's processes were set in motion at the time of its creation by the Secretary of DHHS in 1991. The committee was organized at the request of CDC to provide a setting for guideline development that was free from political or financial influence and that enabled multidisciplinary and public input. Members are recommended by CDC and appointed by the Secretary of DHHS from experts in the fields of infectious diseases, healthcare associated infections, nursing, surgery, epidemiology, public health, health outcomes and related areas of expertise. In fact, the Federal Advisory Committee Act mandates that membership include individuals with a variety of interests, backgrounds and expertise. All HICPAC members are required to regularly disclose potential conflicts of interest. The committee also has ex officio members like the Agency for Healthcare Research and Quality as well as liaisons from professional organizations like the Association for Professionals in Infection Control and Epidemiology Inc., and the Society for Healthcare Epidemiology of America. Other such non-voting representatives are included as the Secretary deems necessary to carry out the functions of the Committee effectively. Since the creation of HICPAC, guidelines have been drafted by CDC in collaboration with outside experts, reviewed and revised within HICPAC, and published in the Federal Register for public comment before final publication.1-3

The content and organization of HICPAC's guidance documents include: 1) a thorough yet concise review of the guideline topic and 2) a recommendations section which communicates strength of recommendations as well as supporting evidence grades. This structure has enabled the committee to differentiate those practices for which the available scientific evidence provides strong support or rejection (Category I) from those practices where there is only suggestive or less definitive evidence (Category II). The grading of the evidence behind the recommendation has also allowed the committee to differentiate strong recommendations with a firm scientific foundation (Category IA) from strong recommendations with a weaker scientific foundation (Category IB). The more recent introduction of Category IC recommendations has enabled a further distinction of strong recommendations mandated by federal and/or state statutes, regulations or standards.

The value of HICPAC documents is reflected in their use by individual infection preventionists and healthcare epidemiologists 4, as well as national societies committed to infection prevention and control5. In addition, the value of HICPAC documents is reflected in a growing body of evidence suggesting they enhance the quality and safety of patient care 6-10. For example, Manangan and others demonstrated an association between a high level of awareness and adoption of HICPAC recommendations with a decrease in the incidence of ventilator-associated pneumonia (VAP) among 188 hospitals.10 Likewise, almost 90% of direct care providers were aware of recommendations in CDC's Hand Hygiene Guideline, and increased adherence with these recommendations correlated with a lower incidence of central line-associated bloodstream infections (CLABSI).7 Several other recent investigations have provided indirect evidence that HICPAC recommendations applied in "bundles" can result in significant reductions in the incidence of CLABSI.6, 8, 9